Professional Issue Forum: You work where? Why? The Realities of Rural/Remote Occupational Therapy Practice

Transcription

1 Report of the Professional Issue Forum on You work where? Why? The Realities of Rural/Remote Occupational Therapy Practice Banff, AB CAOT Conference April 2016 Professional Issue Forums (PIFs) are held annually at the Canadian Association of Occupational Therapists (CAOT) Conference. PIFs address priority health and social issues, and emerging practice areas in occupational therapy. PIFs involve presentations from a panel of experts and participants are invited to contribute their perspectives. The discussion leads to strategies and recommendations for action for CAOT, individual occupational therapists and stakeholders to advance occupational therapy practice and the profession s presence in these areas. CAOT s PIF on the realities of rural/remote occupational therapy practice was held on April 20, 2016, in Banff, Alberta. Professional Issue Forum: You work where? Why? The Realities of Rural/Remote Occupational Therapy Practice April 20, :30pm-5:30pm New Brunswick Room, Fairmont Banff Springs, Banff, Alberta Les Smith Facilitator; Giovanna Boniface- CAOT Staff 2:30-2:40 Introduction from CAOT Les Smith 2:40-2:50 Panelist Presentation- Les Smith Background for Professional Issue Forum 2:50-3:10 Panelist Presentation- Jenna Schuweiler The Quest for Knowledge in Rural Occupational Therapy 3:00-3:10 Panelist Presentation: Kathy Gillis Obtaining, Building and Sustaining Occupational Therapy Teams in Rural Alberta 3:10-3:20 Panelist Presentation: Robin Roots Perspectives from Occupational Therapists in Rural Practice in Northern BC 3:20-3:30 Panelist Presentation: Martine Brousseau Community of Practice to Support Evidence Based Practice: Project Implemented in a Rural Area 3:30-4:20 Roundtable Discussions Questions at each roundtable 4:20-4:30 BREAK 4:30-5:30 Regroup Review Questions/Responses from Each Roundtable

2 About the Participants: Professional Issue Forum Organizer: Giovanna Boniface, B.Sc. (Bio), B.Sc. (OT) is the Managing Director of CAOT-British Columbia Chapter. She is also a University of British Columbia Master of Rehabilitation Science student. Giovanna can be reached at gboniface@caot.ca. Professional Issue Forum Facilitator and Panelist: Les Smith is an occupational therapist and is the CAOT board director for British Columbia and works in Prince George. Panelists: Kathy Gillis is an occupational therapist and the Acting Manager OT- West, Alberta Health Services (South Zone). Jenna Schuweiler is an occupational therapist in Peace River Community Health Centre, Alberta Health Services (North Zone). Dr. Martine Brousseau, is an occupational therapist and Professeure d ergothérapie, Université du Québec à Trois Rivières. Robin Roots is a physiotherapist and Coordinator of Clinical Education Northern & Rural Cohort, UBC Faculty of Medicine Department of Physical Therapy Professional Issue Forum Assistant: Nicole Matichuk is a Master of Occupational Therapy student graduating from the University of British Columbia in November INTRODUCTION: About 90% of Canada s land mass can be considered rural/remote and is home to roughly 1/3 of Canada s population (Williams & Kulig, 2011). By contrast, recent statistics on the occupational therapy (OT) workforce reports that only 5.5% work in rural/remote areas of the country. The largest percentages of OTs working in rural/remote Canada are in the Territories (~33%), the Maritimes (~15%) and Manitoba (~14%). British Columbia (~4%) and Ontario (~2%) have the fewest (CIHI, 2013). Rural Canadians often have higher levels of chronic diseases, lower levels of self-reported functional health and health promotion behaviours. Rural/remote residents are also at higher risks for accidents, suicide and disability compared to urban counterparts (Williams & Kulig, 2011). Addressing health care for Canadians living in rural/remote areas requires an

3 understanding of rural health, health practices in rural areas, the complexity of delivering services in rural areas, and of rurality and how this affects health (Roots, et al., 2014). Often, OTs who choose to work in rural/remote parts of Canada find it challenging from many perspectives ranging from having a solid understanding of the determinants of health to learning to practice as a generalist in interdisciplinary teams. Yet these OTs find this type of practice rewarding (Roots, et al., 2014). Recruitment and retention of OTs in rural/remote areas has long been found to be difficult. Some factors that contribute to successful recruitment have been rural/remote origin, proximity to family and rural education (Winn, et al., 2014). Job satisfaction and lifestyle have been identified as positive retention factors (Winn, et al., 2014). So why are so few OTs working in these areas? For those that are, what is keeping them in rural/remote parts of Canada? What would help to attract more OTs to work in these areas? How can OTs working in urban or rural/remote settings work more closely together to meet the needs of clients? What stories do we have to tell that can help other OTs understand the importance of rural/remote practice? INITIATIVE Participants in the professional issues forum (PIF) will broaden their knowledge and understanding of rural and remote practice and contribute to increasing the knowledge base about rural and remote occupational therapy practice. OBJECTIVES: 1. To explore and document the role occupational therapists have and can develop in rural and remote practice; 2. To identify the resources that exist and that are required to support occupational therapists involved in or interested in rural and remote practice; 3. To identify collaborative practices used by rural and urban occupational therapists; 4. To gain an understanding of the current research and evidence related to rural and remote practice; 5. To gain an understanding of how health, education, and social policy affects rural and remote practice. SUMMARY OF PANEL PRESENTATIONS: Jenna Schuweiler Jenna shared her experience of being a new graduate, describing positive aspects and challenges of working in a rural setting. She gained increased confidence and improved assertiveness, and also experienced effective interprofessional collaboration. She felt that being eager and open minded helped her to succeed in a rural environment and found the experience

4 to be character building. She identified her greatest challenges as a lack of practice experience, lack of specialist knowledge, lack of available occupational therapist colleagues for support and high caseload requirements. She suggested that support for new graduates could be improved with the provision of more local workshops, free access to journals and more professional practice leaders. Kathy Gillis Kathy s presentation emphasized that an important goal of the profession is the same in rural and urban areas: fair and equitable access to occupational therapy. The lack of access in rural areas is problematic and poses an ethical dilemma. Kathy also discussed recruitment and retention of occupational therapists and occupational therapist assistants. Kathy emphasized that one of the greatest benefits of working in a rural setting is the ability to build relationships within the community working with neighbours. Robin Roots Robin discussed a qualitative study examining what it means to work in rural/remote practice. Research was conducted with occupational therapists and physiotherapists in communities with fewer than 15,000 people. Robin reviewed three key themes from her results: specializing in general practice, stretching roles and participation/partnership in community. Robin suggested that occupational therapists in rural/remote areas need to be very resourceful and brave, as well as willing to build networks, use technology and become increasingly reflective practitioners. Dr. Martine Brousseau Dr. Brousseau presented a study that explored the question of whether evidence-based practice (EBP) is more challenging in rural areas. Challenges highlighted included isolation, limited time and access to technology, limited support and few opportunities to receive fieldwork students. Dr. Brousseau reported that the study caused a shift in occupational therapy practice and behaviour, leading to more use of EBP among study participants. Following the presentations, attendees were asked organize into roundtable groups to reflect on the panel presentations and their own experiences in rural/remote practice. SUMMARY OF ROUNDTABLE DISCUSSION: Seven (7) roundtables with a total of 52 participants took part in the roundtable discussion. Roundtable participants were asked to discuss and document responses to the following questions. Question 1 Share your experiences from rural & remote practice. If you work in an urban setting share why? Participant responses included:

5 Living in a rural setting brings a passion to wanting students to have a positive experience on placements in a rural setting I work rural because it s roots/home Staying in a rural setting can be influenced by meeting a partner in those settings Find that rural community members (schools, etc.) are open to working with the OT even more Opportunity for underserviced areas grants to help pay off student loans after graduation Like being a generalist and connecting with the community Important to connect with network of OTs for support/idea sharing Went rural to try something new as a new grad Working in an urban setting has many opportunities for professional development gone urban Growing up rurally tends to draw you back to rural settings to live and work depending on job opportunities I am a big city gal. I thrive on chaos (urban) Served the whole region; inpatient, outpatient, personal care homes in 3 major settings and towns in between (Flin Flan and Thompson regions) Offered a signing bonus, mileage and relocation allowance (Northern Alberta) Outsiders not part of the community; a challenge to break in (Smithers) Social part of community is deal-breaker (Smithers) Reasons for going rural- often personal, marrying local, following family, availability of work Advocating for rural practice- grasping the opportunity to advocate Lack of mental health services Affected by shortages Geography driven practice Determinants of health for first nations persons are poor Challenges to access tertiary care services Communities have expectations of service Sometimes do more with less- just do it (rural) Increased time taken to provide service and equipment Extremely hard to find OTs in rural/remote areas Hard to network and find resources Difficulties in recruitment and retention lead to scope creep Bursary effective in recruitment Stayed because of love of developing expertise in Saskatchewan Support of non-ot colleagues and supervisor instrumental in recruitment and retention More availability of positions in urban centres Office may be in an urban setting but practice may extend to rural areas Rural is a subjective concept may be in areas of 10,000 people, but considered urban by other communities

6 Great, fun stories; Love providing service that people wouldn t get otherwise The community knows me and what I do. I like this Shifting focus from physical medicine to mental health The client is so empowered; they are willing to say No; Can t fake care rurally They are your personal community; they can trust you because of this Collaborative practice just comes naturally Structures/rules can lead to stove piping/silos which create artificial but significant barriers Even less likely to have a manager who is aware of what OT practice is Question 2 What resources exist that support your rural/remote practice? What resources exist that support your urban practice? What resources are needed to enable your rural/remote practice? As an urban practitioner, what resources do? Participant responses included: Training resources- where can rural practitioners go to get trained? Not offered rurally. How do we build capacity in rural communities? Lack of health human resources Less FTE than should be available Better communication between tertiary care to rural practitioners Current role of OT in rural hospitals is that of discharge planning. Not able to work to full scope (assessment, treatment) Do nothing but discharge Better distribution of clinic specialty Need to e more mobile Need to be open for residents of remote communities/jurisdictions Limitation of telehealth is that you need the certification (why do you need a specialist/trained therapist at both ends?) Specialized service delivery that is rural based- a hybrid model (e.g. special back for a wheelchair- consult with specialist) Having a rural/remote community of practice facilitated by CAOT would be helpful (website says this is available but it is not) Issue- consistency in practice Urban practitioners can provide phone help to rural/remote practitioners Rural resource- seating clinics, mental health practice leads from Edmonton, telehealth and other distance education, community of practice, good internet access, Alberta provincial OT practice council Rural resource needs: resources for first nations communities, practice leads (in Yukon there is no practice leader), access to face-to-face education, improved ease of access to new information/resources Consistent electronic medical records We need a resource hub for rural/remote practice through provincial association

7 Need more flexible resources (e.g. timeline of events, conferences) as some timelines do not work. Also issue of cost and travel Need allied health meet-ups Need special training for issues in rural practice (e.g. trauma informed care in aboriginal populations) Internet is a great rural resource Non-medical professionals (e.g. pastors) can be useful on team Lunch and learns only available at lunch in Eastern Canada Cost scheme that support rural participation (webinars) Resources have increased- internet, webinars, teleconferences, but it is expensive Access to vendors- limited choices in rural/remote Face to face meeting with rural OTs Assessment resources- not as needed- generalist approach tends to support client specific do what is needed Access to answers to research questions is quite good (e.g. library) Rural- difficult to trial equipment with vendors (e.g. getting wheelchairs to clients) Create a network of experts that you can call and chat with (e.g. seating) Organizations in area offering training- take opportunities when employers pay for it Connect with other OTs when you can Online resources, lunch and learn webinars Take opportunities to reach out to community members to share your knowledge Teaching others helps you learn Create discussions with community members Use your professional associations for knowledge and connecting with other OTs Question 3 Collaborative practice must occur to enable clients best occupational outcomes through their health continuum of care. In what ways do you as an urban OT support clients return to their homes/communities in rural/remote locations? As a rural OT, how effective is this collaborative practice for client occupational outcomes? Participant responses included: Helpful to have specialist OTs provide a home program/recommended treatment plan for a client they are referring to my rural area, so it is easier for me to follow-up Urban to rural- predischarge consultation to determine what service are available Rural perspective- great when it works; not great when it doesn t (e.g. client expectations that can t be met) Encourage bi-directional resource sharing between rural and urban areas to support each other Currently need to be creative in this field- communicate with phones; meet with team/client in various settings; important of home care and community care in discharge Importance of planning/knowing/utilizing resources and using therapy assistants Need for therapy assistants in rural practice

8 Knowing the team becomes extremely important because you may have to communicate over the phone or teleconference which can be more challenging Collaborate with community members on broad level by taking opportunities to teach each other about your knowledge (e.g. talking to a school about use of alternative seating) When employers are unaware of OT be prepared for discussion and advocate for your role Question 4 How can we support clinicians moving into a rural/remote area? (e.g. new graduates, clinicians). What could the occupational therapy community do to support a) new graduates b)clinicians new to rural/remote practice (e.g. professional associations, regulators, educators, employers, other)? Participant responses included: How do we protect therapists from burn out? What responsibilities does the community have to support therapists? We need a Siri for OTs How can we develop a community of practice for rural OTs? Standardized protocols (e.g. discharge communication) For a generalist, how to make it easier to navigate the array of resources out there List of apps and client handouts- where do I go for best fall prevention handout? Podcasts/videocasts- recorded Recruitment with clinical placements- e.g. special visits to rural settings rather than a long commitment Perceptions of fieldwork supervisors- intimidation by students (do new preceptors take new students?); do students value a rural clinicians experience? Financial support Mentorship Providing resources (people/finances) to do an excellent job of mentoring for as long as needed (it takes longer than you think) Consistent mentoring Excellent orientation Plug them into a social network locally Increase clinical placements Financial support for rural placement We need to support citizens from rural and remote to become OTs- the challenge is that many individuals do not finish school Mentorship is key early on Need to foster development of online programs to enable education of OTs with their community Strong regulatory body/organization to support rural areas (training in other areas) Promote mentorship Use of technology/telehealth a good avenue to progress and support clinicians

9 Encourage students/new grads to connect with therapists in rural areas- shadow OTs, spend time in a rural setting Help new grads seek mentorship Professional associations present to students/grads on how to seek mentorship Support/advocate for OT to upcoming students from the community Question 5 What is required to better prepare future clinicians for rural/remote practice? Participant responses included: Tell students about how professional associations can help and support you if you decide to work rural Instill confidence in students choosing rural Articulating stories of rural/remote practice- can be challenging for clinicians to hear about rural OTs not being able to adhere to best practice standards Change the way curriculum teaches students how to work outside of best practice More placements in rural settings for students Teach students that it is OK to know what you don t know Advocacy to employers that new clinicians need support and mentorship Rural feelings that not enough time/services make a difference Understand alternate models for service delivery Practice adapting city interventions and best practice to rural contexts- e.g. case studies Teach more hard skill sets Clinical prioritization skills How to say no How to switch clinical gears on the fly (e.g. switching between varied caseloads in same day) Universities need to offer stipends to students coming to rural practice Identify the curriculum to understand the pleasures and pressures of rural practice Getting professionals prepared to be able to say I don t know Clinical professional development Mentorship Telehealth is better than nothing Telehealth consultation for specific clients Tools/resources for prioritization Require rural placements to maximize exposure Use role emerging strategies to support Save some seats for rural students

10 Question 6 Describe client access to OT services in your community as compared with an urban/remote community. What collaborative strategies would enable fair and equitable access to OT services for rural/remote clients? Participant responses included: Clients need to fly-in/drive distances if you don t have funding to go to them Using teleconference to connect Travelling to communities Significantly reduced services Inconsistent services First nation elders access less services (sometimes due to cost of services) Issue of long term care= similar to residential school Generally rural areas are under-serviced for OT when compared to urban Strategy= increase funding for FTE Face to face- often immediate in my rural area AADL program in Alberta- increased funding for equipment going out to rural areas to support vendors who incur extra costs CAOT- provide education that is less cost to rural therapists because we are not part of a group that can access information together No roads, no cell service in my region (Fox River) 2 hours away to see a client/medical facility transfer- greyhound takes 10 hours Waitlist is shorter Service is more personable You end up serving friends More telehealth Telehealth is unreliable Access to diagnostics- e.g. pressure mapping Question 7 What research priorities and actions would contribute further to policy change, resource allocation and engagement of OTs to work rurally/remotely? Participant responses included: What are the right questions to ask in an interview to find OTs that fit and stay in rural practices? Support education and exploration on alternate models of service delivery Culturally relevant service delivery for indigenous communities, models that will help compensate for the under-supply of OTs, community-based rehab approaches, etc. Explore use of rehab assistants from the rural communities (people who are from the community and can help with continuity of care when OTs turnover frequently) Better e-health communication

11 Engage front line leadership to understand policies and be able to support practical application in rural communities Role of professional association to help synthesize policy changes Encourage rural/remote therapists to participate on College and boards Question 8 What strategies would you recommend to explore with leadership on the value of OT with current models of care (provincial, national, healthcare, education, or social justice systems)? Participant responses included: Video presentations of stories of OTs who have worked in rural/remote areas and the pros and opportunities and experiences that they could share to aid promotion, recruitment and retention Better partnerships between Ministries Creation of innovative positions/new models of care to fill traditional roles/vacancies New grads/millennials don t want traditional jobs SUMMARY Attendees were asked to reflect on the panel presentations and their own experiences in rural/remote practice. Many valuable points were brought up throughout the discussions. Challenges and benefits of rural/remote practice Being a generalist, as therapists often must be in rural communities, brought about both challenges and benefits. This descriptor was seen as beneficial because a generalist can treat all clients without risking exclusion due to specialization; however, at times being a generalist meant not always knowing the answer. Collaboration with clients and other health professionals was also discussed as a benefit, and several occupational therapists described the significant impacts of their relationships with their communities. Recruitment and retention Participants strongly emphasized the need to attract and keep students and new graduates. Suggested strategies to support this requirement included teaching grade school students in rural areas about occupational therapy, encouraging occupational therapists working in rural areas to take fieldwork students and establishing strategies for mentorship. Other related suggestions included reserving spaces in occupational therapy programs for students who are from (and likely to return to) rural/remote communities, as well as educating students more thoroughly about the realities of rural/remote practice, providing them with culturally relevant case studies and information about service delivery models. Directions for improvement Many suggestions were made regarding how best to support rural/remote practice; most centered on improving access to resources, such as mobile specialty clinics, electronic resources, vendors and other occupational therapists working in similar areas. Existing

12 resources vary across regions and are often limited; therefore, increasing the diversity of resources and access to telehealth could improve practice. Urban centres could also potentially support surrounding or specific rural areas. It was also suggested that occupational therapists working in rural/remote areas participate in provincial and national boards to contribute their unique viewpoints. RECOMMENDATIONS Delegates validated the need for CAOT and provincial professional associations to provide support to occupational therapists working in rural/remote locations. CAOT has many existing resources including practice networks and educational opportunities available to rural/remote clinicians; however most participants were not aware of or did not know how to access these existing resources. It is recommended that CAOT facilitate and improve access to these resources through existing and new communication channels (e.g. OT Weekly, invitations, resource orientation webinars, website portal). In addition, it is recommended that CAOT consider the addition of rural/remote clinicians in the planning of professional development offerings in order to ensure the regional needs of clinicians are heard, for example, could a national advisory committee be struck to inform CAOT learning services? Finally, it is also recommended that CAOT help front-line occupational therapists understand federal and provincial government health policy publications, policy changes and initiatives around rural health and the influence on practice.

13 Appendix A REFERENCES Canadian Institute of Health Information. (2013). Occupational Therapist Workforce, 2012 [Data file]. Retrieved from Roots, R. K., Brown, H., Bainbridge, L., & Li, L. (2014). Rural rehabilitation practice: Perspectives of occupational therapists and physical therapists in British Columbia, Canada. Rural and Remote Health, 14. Retrieved from Williams, A. M., & Kulig, J. C., (2011). Health and place in rural Canada. In J. C. Kulig & A. M. Williams, (Eds.) Health in rural Canada (pp. 1-22). Vancouver, BC: UBC Press. Winn, C. S., Chisolm, B. A., & Hummelbrunner, J. A. (2014). Factors affecting recruitment and retention of rehabilitation professionals in Northern Ontario, Canada: A cross-sectional study. Rural and Remote Health, 14. Retrieved from RESOURCES Matichuk, N., Boniface, G & Smith, L. (2016). CAOT Professional Issue Forum: You Work Where? Why? The Realities of Rural/Remote Occupational Therapy Practice. Ottawa, ON: CAOT Publications ACE